Clinical Diagnostic Laboratory Fee Schedule 2016

$79 / year

This dataset contains the clinical diagnostic laboratory fee schedule revised for January 2016. The update includes all changes identified in Change Request (CR) 9465.

Complexity

Outpatient clinical laboratory services are paid based on a fee schedule in accordance with Section 1833(h) of the Social Security Act. Payment is the lesser of the amount billed, the local fee for a geographic area, or a national limit. In accordance with the statute, the national limits are set at a percent of the median of all local fee schedule amounts for each laboratory test code. Each year, fees are updated for inflation based on the percentage change in the Consumer Price Index. However, legislation by Congress can modify the update to the fees. Co-payments and deductibles do not apply to services paid under the Medicare clinical laboratory fee schedule.

Each year, new laboratory test codes are added to the clinical laboratory fee schedule and corresponding fees are developed in response to a public comment process. Also, for a cervical or vaginal smear test (pap smear), the fee cannot be less than a national minimum payment amount, initially established at $14.60 and updated each year for inflation.

Critical access hospitals are paid for outpatient laboratory tests on a reasonable cost basis, instead of by the fee schedule. Hospitals with fewer than 50 beds in qualified rural areas—those with population densities in the lowest quartile of all rural areas—are paid based on a reasonable cost basis for outpatient clinical laboratory tests for cost reporting periods between July 2004 and July 2006.

Note: Where modifier is shown in the dataset, QW denotes a CLIA waiver test.The QW modifier states that the tests you are performing are “simple laboratory examinations and procedures that have an insignificant risk of an erroneous result”. They are considered “CLIA waived” and therefore require a “CLIA Certificate of Waiver”.

Date Created

2015-12-15

Last Modified

2015-12-15

Version

2015-12-15

Update Frequency

Annual

Temporal Coverage

N/A

Spatial Coverage

United States

Source

John Snow Labs => Centers for Medicare and Medicaid Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

Medicare Schedule, Diagnostic Laboratory Fee Schedule, Outpatient Clinical Laboratory Services, Outpatient Laboratory Services, Medicare Clinical Laboratory Fee Schedule, Critical Access Hospitals, Blood Laboratories, Medicare Laboratory Schedule, Clinical Laboratories, Diagnostic Laboratories

Other Titles

Blood Lab Clinical Diagnostic Laboratory Fee Schedule 2016, Medicare Schedule Clinical Diagnostic Laboratory Fee Schedule 2016, Clinical Laboratory Diagnostic Fee Schedule 2016

NameDescriptionTypeConstraints
HCPCS_CodeHCPCS, The Healthcare Common Procedure Coding System, includes All current year active CPT and alpha-numeric codes subject to the Clinical Laboratory Fee Schedule.stringrequired : 1
Description_of_HCPCS_CodeShort description of HCPCS Codestringrequired : 1
Is_QW_ModifierWhere modifier is shown, QW denotes a CLIA waiver test. The QW modifier states that the tests you are performing are "simple laboratory examinations and procedures that have an insignificant risk of an erroneous result". They are considered "CLIA waived" and therefore require a "CLIA Certificate of Waiver".boolean-
National_Limitation_Amount60% National Limitation Amount is set at 74% of the 2016 median. The 62% NLA is calculated using the following algorithm: ((60% NLA / 0.60) * 0.62). If the floor is applicable, then the NLA is appropriately adjusted.numberlevel : Ratio
Mid_Point_of_Base_Fee_Amounts60% Median (2016) - Median of the 2016 60% Updated Base Fee Amounts from all Medicare Part B Carriers.numberlevel : Ratio
Payment_Floor60% Floor (2016) - BBRA of 1999 requires a payment floor for all Pap Smears; the 62% floor equals the 60% floor.numberlevel : Ratio
Northern_California60% Pricing Amount in the state of Northern Californianumberlevel : Ratio
Southern_California_Occidental60% Pricing Amount in the state of Southern California Occidentalnumberlevel : Ratio
Hawaii60% Pricing Amount in the state of Hawaiinumberlevel : Ratio
Nevada60% Pricing Amount in the state of Nevadanumberlevel : Ratio
Alaska60% Pricing Amount in the state of Alaskanumberlevel : Ratio
Idaho60% Pricing Amount in the state of Idahonumberlevel : Ratio
Oregon60% Pricing Amount in the state of Oregonnumberlevel : Ratio
Washington_State60% Pricing Amount in the state of Washington Statenumberlevel : Ratio
Arizona60% Pricing Amount in the state of Arizonanumberlevel : Ratio
Montana60% Pricing Amount in the state of Montananumberlevel : Ratio
North_Dakota60% Pricing Amount in the state of North Dakotanumberlevel : Ratio
South_Dakota60% Pricing Amount in the state of South Dakotanumberlevel : Ratio
Utah60% Pricing Amount in the state of Utahnumberlevel : Ratio
Wyoming60% Pricing Amount in the state of Wyomingnumberlevel : Ratio
Colorado60% Pricing Amount in the state of Coloradonumberlevel : Ratio
New_Mexico60% Pricing Amount in the state of New Mexiconumberlevel : Ratio
Oklahoma60% Pricing Amount in the state of Oklahomanumberlevel : Ratio
Texas60% Pricing Amount in the state of Texasnumberlevel : Ratio
Iowa60% Pricing Amount in the state of Iowanumberlevel : Ratio
Kansas_I60% Pricing Amount in the state of Kansas_Inumberlevel : Ratio
Kansas_II60% Pricing Amount in the state of Kansas_IInumberlevel : Ratio
Missouri60% Pricing Amount in the state of Missourinumberlevel : Ratio
Missouri_General_Amer60% Pricing Amount in the state of Missouri General Amernumberlevel : Ratio
Nebraska60% Pricing Amount in the state of Nebraskanumberlevel : Ratio
Illinois60% Pricing Amount in the state of Illinoisnumberlevel : Ratio
Minnesota60% Pricing Amount in the state of Minnesotanumberlevel : Ratio
Wisconsin60% Pricing Amount in the state of Wisconsinnumberlevel : Ratio
Arkansas60% Pricing Amount in the state of Arkansasnumberlevel : Ratio
Louisiana60% Pricing Amount in the state of Louisiananumberlevel : Ratio
Mississippi60% Pricing Amount in the state of Mississippinumberlevel : Ratio
Indiana60% Pricing Amount in the state of Indiananumberlevel : Ratio
Michigan60% Pricing Amount in the state of Michigannumberlevel : Ratio
Florida60% Pricing Amount in the state of Floridanumberlevel : Ratio
Puerto_Rico60% Pricing Amount in the state of Puerto Riconumberlevel : Ratio
Alabama60% Pricing Amount in the state of Alabamanumberlevel : Ratio
Georgia60% Pricing Amount in the state of Georgianumberlevel : Ratio
Tennessee60% Pricing Amount in the state of Tennesseenumberlevel : Ratio
South_Carolina60% Pricing Amount in the state of South Carolinanumberlevel : Ratio
Virginia60% Pricing Amount in the state of Virginianumberlevel : Ratio
West_Virginia60% Pricing Amount in the state of West Virginianumberlevel : Ratio
North_Carolina60% Pricing Amount in the state of North Carolinanumberlevel : Ratio
Delaware60% Pricing Amount in the state of Delawarenumberlevel : Ratio
District_of_Columbia60% Pricing Amount in the state of District of Columbianumberlevel : Ratio
Maryland60% Pricing Amount in the state of Marylandnumberlevel : Ratio
New_Jersey60% Pricing Amount in the state of New Jerseynumberlevel : Ratio
Pennsylvania60% Pricing Amount in the state of Pennsylvanianumberlevel : Ratio
Connecticut60% Pricing Amount in the state of Connecticutnumberlevel : Ratio
Empire_New_York60% Pricing Amount in the state of Empire New Yorknumberlevel : Ratio
Western_New_York60% Pricing Amount in the state of Western New Yorknumberlevel : Ratio
New_York_GHI60% Pricing Amount in the state of New York GHInumberlevel : Ratio
Maine60% Pricing Amount in the state of Mainenumberlevel : Ratio
Massachusetts60% Pricing Amount in the state of Massachusettsnumberlevel : Ratio
New_Hampshire60% Pricing Amount in the state of New Hampshirenumberlevel : Ratio
Rhode_Island60% Pricing Amount in the state of Rhode Islandnumberlevel : Ratio
Vermont60% Pricing Amount in the state of Vermontnumberlevel : Ratio
Kentucky60% Pricing Amount in the state of Kentuckynumberlevel : Ratio
Ohio60% Pricing Amount in the state of Ohionumberlevel : Ratio
HCPCS_CodeDescription_of_HCPCS_CodeIs_QW_ModifierNational_Limitation_AmountMid_Point_of_Base_Fee_AmountsPayment_FloorNorthern_CaliforniaSouthern_California_OccidentalHawaiiNevadaAlaskaIdahoOregonWashington_StateArizonaMontanaNorth_DakotaSouth_DakotaUtahWyomingColoradoNew_MexicoOklahomaTexasIowaKansas_IKansas_IIMissouriMissouri_General_AmerNebraskaIllinoisMinnesotaWisconsinArkansasLouisianaMississippiIndianaMichiganFloridaPuerto_RicoAlabamaGeorgiaTennesseeSouth_CarolinaVirginiaWest_VirginiaNorth_CarolinaDelawareDistrict_of_ColumbiaMarylandNew_JerseyPennsylvaniaConnecticutEmpire_New_YorkWestern_New_YorkNew_York_GHIMaineMassachusettsNew_HampshireRhode_IslandVermontKentuckyOhio
81538Oncology lungfalse
81545Oncology thyroidfalse
81440Mitochondrial genefalse
81525Oncology colon mrnafalse
81417Exome re-evaluationfalse
81427Genome re-evaluationfalse
0010MOnc prostate prob scorefalse
81493Cor artery disease mrnafalse
81416Exome sequence analysisfalse
81415Exome sequence analysisfalse